Integrated Quality & Performance Report Public Board€¦ · Integrated Quality & Performance Report Public Board 27th March 2014 Presented for: Information Presented by: Dr Mark

Integrated Quality & Performance Report

Public Board

27th March 2014

Presented for: Information

Presented by: Dr Mark Smith, Chief Operating Officer

Author: Information Department

Previous Committees:

None

Trust Goals

The best for patient safety, quality and experience

The best place to work

A centre for excellence for research, education and innovation

Seamless integrated care across organisational boundaries

Financial sustainability

Key points

This report is presented to ensure the Board remains up-to-date with the Trust’s performance in light of national requirements and local developments.

Information

Agenda Item 22.1

THE LEEDS TEACHING HOSPITALS NHS TRUST

TRUST BOARD MEETING – MARCH 2014

INTEGRATED QUALITY &

PERFORMANCE REPORT

PERIOD – FEBRUARY 2014

Contents

Overview of Performance ............................................................................................................. 1

Summary ...................................................................................................................................... 2

AF Quality and Governance Dashboard ............................................................................ 3

Shadow Monitor Risk Assessment Framework ................................................................. 5

Narrative ...................................................................................................................................... 6

Referral To Treatment (RTT) ............................................................................................. 6

RTT Clearance Times ....................................................................................................... 8

Diagnostic Waits ................................................................................................................ 9

Cancelled Operations ...................................................................................................... 10

A&E Waiting Times (4 Hours) .......................................................................................... 11

A&E Measures ................................................................................................................ 12

Cancer 62 Days ............................................................................................................... 14

Cancer 31 Days ............................................................................................................... 16

Cancer 2 Week Wait ........................................................................................................ 17

Stroke Care ..................................................................................................................... 18

30 Day Emergency Readmissions................................................................................... 19

Outpatient Activity - New and Review.............................................................................. 20

Inpatient Activity - Elective and Non-elective ................................................................... 21

Length of Stay ................................................................................................................. 22

Incidence of MRSA .......................................................................................................... 23

MRSA Screening ............................................................................................................. 24

Incidence of CDI .............................................................................................................. 25

Summary Hospital Mortality Index (SHMI) ....................................................................... 26

Hospital Standardised Mortality Rate (HSMR) ................................................................ 27

VTE Risk Assessment ..................................................................................................... 28

Harm Free Care............................................................................................................... 29

Pressure Ulcers ............................................................................................................... 30

Complaints ...................................................................................................................... 31

Patient Satisfaction – Friends & Family ........................................................................... 32

Outpatient Measures ....................................................................................................... 33

Outpatient Measures (Continued).................................................................................... 34

Choose and Book (CAB) – ASIs ...................................................................................... 35

CAB - Utilisation .............................................................................................................. 36

Workforce ........................................................................................................................ 37

Finance ...................................................................................................................................... 38

AF Finance Dashboard .................................................................................................... 38

Finance - In-Year Financial Delivery Indicators ............................................................... 39

Finance - Progress Towards Foundation Trust Status .................................................... 39

Internal Indicators Dashboard .................................................................................................... 40

Appendix 1 - Updates................................................................................................................. 42

Appendix 2 - Peer Groups .......................................................................................................... 43

Appendix 3 - Glossary ................................................................................................................ 44

Page 1 of 44

Overview of Performance

Overview:

The IQPR has been developed to include all measures contained within the NHS Trust Development Authority’s (TDA) Accountability Framework (AF) and Monitor’s Risk Assessment Framework (RAF) Service Performance Score. The latest performance against national and local CQUIN (Commissioning for Quality & Innovation) requirements, local contract quality requirements and key internal measures are also reported where appropriate.

In time, Trusts will be rated monthly against the 3 domains within the AF’s Oversight Model (Quality & Governance, Finance and Delivering Sustainability). The methodology for rating overall performance as well as the detail behind the definition and thresholds for acceptable performance for a number of these metrics has yet to be confirmed by the TDA. The TDA has, however, intimated it will soon begin publishing the Oversight Model.

Access:

Trust compliance with the target to treat 95% of non-admitted patients within 18 weeks, and for 92% of patients on incomplete pathways to have waited less than 18 weeks, was maintained in February. The Trust remains non-compliant with the standard to treat 90% of admitted patients within 18 weeks.

The Trust level 4 hour A&E access standard was failed in February, having previously been achieved each month since June 2013. Performance against this indicator was however restored for the first 2 weeks of March (as reported on page 11).

Capacity constraints and late referrals from other providers continue to impact on the Trust’s ability to maintain the 62 day standard for urgent GP referral to cancer treatment. Performance in January was also below standard for two of the other cancer standards: the 2 week wait target for suspected cancer, and the 31 day target for subsequent radiotherapy.

Outcomes:

There were no cases of MRSA apportioned to the Trust in February. In addition, Trust level performance against the requirement to screen 95% of eligible patients was maintained for the fourth consecutive month.

There were 9 cases of C. difficile infections (CDIs) at the Trust in February. Year-to-February there were 135 CDIs against the goal of no more than 101 for the full year.

The rate of E. Coli and MSSA cases per 100,000 bed days rose above the thresholds set by the TDA in February, at 95.5 (against a threshold of 94.9) and 10.2 (against a threshold of 9.02) respectively.

The Trust continues to maintain an overall Summary Hospital Mortality Index (SHMI) and Hospital Standardised Mortality Rate (HSMR) within or better than the expected range, as of the latest available position from Dr Foster (July 2012 to June 2013).

Quality Governance:

The Trust continues to achieve against the targeted response rate for the Friends and Family Test (FFT), with the overall response rate for February reported at 26.5% against a TDA threshold of 20%.

In January, the Trust’s FFT Net Promoter Score (which evaluates the proportion of respondents who would be extremely likely to recommend services minus the proportion who would not) matched the national average of 65. The Trust’s overall score for February was 62.1.

Page 2 of 44

Indicator Group Group Description

National Indicators / Quality Requirements Indicators are included from the AF, which is used by the TDA to monitor the performance of non-Foundation Trusts (FTs), as well as Monitor’s RAF Service Performance Score (this will be in shadow form until the Trust becomes an FT). These are national targets Trusts must achieve and incorporate indicators measuring access, quality, outcomes and finance. These include the MRSA and C. difficile (CDI) objective, A&E waiting times, referral to treatment (RTT) and cancer waits, patient experience and risk assessments of venous thromboembolism (VTE).

CQUIN Indicators

National and local CQUINs indicators are incorporated; these include indicators around the Safety Thermometer, dementia and patient discharge. The CQUIN summary dashboard is included on a quarterly basis.

Local Contractual Indicators Data indicators that form part of the Trust’s Contract agreement with the Clinical Commissioning Groups (CCG).

Internal Indicators Internal indicators are metrics that are key to the Trust’s success, that have not been incorporated previously. These include further information around RTT on clearance times, stroke care, inpatient and outpatient activity, and research and innovation (R&I) indicators.

Leeds Teaching Hospitals Trust (LTHT) Summary

This report covers national performance measures from the Trust Development Authority’s (TDA) Accountability Framework (AF) and Monitor’s Service Performance Score (part of the RAF). Relevant CQUIN indicators which are not already incorporated within the National Indicators are also included on a quarterly basis, as well as selected local contractual indicators and additional internal metrics. Updates from regulators are included in Appendix 1. (Please note this report is a work in progress, and there is not therefore a section for all indicators).

Page 3 of 44

AF Quality and Governance Dashboard

Category Indicator Dec-13 Jan-14 Feb-14 YTD

Referral to treatment within 18 weeks - admitted > 90% 87.3% 86.0% 88.7% 85.4%

Referral to treatment within 18 weeks - non-admitted > 95% 95.4% 95.0% 95.5% 95.5%

Referral to treatment within 18 weeks - incomplete > 92% 94.1% 94.6% 95.2% n/app

Referral to treatment within 18 weeks - over 52 week waiters (incomplete waits) 0 0 0 n/app

Diagnostic waits within 6 weeks > 99% 99.6% 99.0% 99.2% n/app

Last minute cancelled operations not re-booked within 28 days

Urgent operations cancelled for the second time

A&E 4 hour > 95% 97.1% 96.1% 93.9% 96.4%

Cancer 62 days - GP referral > 85% 76.3% 78.5% 83.0%

Cancer 62 days - referral from screening service > 90% 90.2% 100.0% 95.7%

Cancer 31 days - first treatment > 96% 97.3% 96.2% 97.3%

Cancer 31 days - second or subsequent surgery > 94% 91.9% 94.3% 96.7%

Cancer 31 days - second or subsequent drug treatment > 98% 100.0% 100.0% 100.0%

Cancer 31 days - second or subsequent radiotherapy > 94% 92.6% 93.3% 97.7%

Cancer 2 week wait - suspected cancer > 93% 94.9% 87.0% 93.2%

Cancer 2 week wait - breast symptoms > 93% 92.0% 93.8% 92.1%

30 day emergency readmissions (Elective & non-elective) < 10.9% 7.2% 6.8%Reported a month

in arrears6.9%

Incidence of MRSA 0 1 0 6YTD: < 94

13/14: < 101

Medication errors causing serious harm - Number 1 0Reported a month

in arrears3

Harm free care (pressure sores, falls, CUTI and VTE) - Safety Thermometer (Snapshot) > 92% 93.2% 93.8% 93.7% n/app

Serious incidents - Number 4 6 12 44

Serious incidents - Rate per 1,000 bed days < 1.23 0.08 0.11 0.24 0.08

Never events 0 0 1 6

E. Coli cases 48 44 47 526

E. Coli cases - Rate per 100,000 bed days 3 < 94.9 93.4 79.9 95.5 92.7

MSSA cases - Rate per 100,000 bed days 3 < 9.02 1.9 10.9 10.2 10.0

Maternal deaths 0 0Reported a month

in arrears1

Summary Hospital-level Mortality Indicator (SHMI)

Hospital Standardised Mortality Ratio (HSMR) (2012/13 rebased)

Venous thromboembolism (VTE) risk assessment > 95% 95.2% 96.1%Reported a month

in arrears95.7%

Q1 > 15%

By Q4 > 20%

Nurse: bed ratio 5 1.92 : 1 1.92 : 1 1.92 : 1 n/app

% of nurses registered nurses > 60% 71.1% 70.3% 70.2% -

Mixed sex accommodation 0 0 0 0

Unavailable 8

Q3: 3.0%0%

0

Qu

ality

Go

ve

rna

nce

Ind

ica

tors Patient satisfaction (friends and family) - Response rate¹ 22.4% 26.5% 20.5%

National Ave: 100

July 2012 to June 2013: 95.15

0.1 : 1 to 4.4 : 1

0

0

13/14: < 1

9 13513 12

n/app

n/app

July 2012 to June 2013: 91.17

National Indicators / Quality Requirements - AF Quality and Governance

TDA Thresholds

Acce

ss M

etr

ics

0

0

Reported a month

in arrears

20.8%

Ou

tco

me

s M

etr

ics

National Ave: 100

0

Incidence of C. Difficile

6

Page 4 of 44

Indicators Awaiting Clarification:

Category Indicator Dec-13 Jan-14 Feb-14 YTD

Warning notice None None None None

Civil and/or criminal action None None None None

Admissions of fullterm babies to neonatal care 2.7% 3.9% 2.3% 3.2%

YTD: < 54

13/14: < 60

C-section rates (Emergency and Elective LSCS) 18.3% 21.4%Reported a month

in arrears20.2%

Open CAS Alerts (Exceeding the deadline for action) 4 6 5 5 n/app

WHO surgical checklist compliance 97.6% 97.3% 97.8% n/app

3rd

Pa

rty

Re

po

rts

Any relevant report including safeguarding alerts, serious case reviews, ad hoc reports from MPs,

GMS, Ombudsman, Commissioners, litigation etc.

Patient satisfaction (friends and family) - Net Promoter Score (DH) ¹ 70.0 65.0 62.1 68.0

Patient and carer voice

Board turnover (12 months rolling average) 50.5% 44.0% 44.0% n/app

Sickness/absence rate (12 months rolling average) 4.2% 4.1% 4.1% n/app

Proportion temporary staff – clinical and non-clinical 7.4% 8.7% 8.5% n/app

Staff turnover (12 months rolling average) 10.8% 10.8% 10.6% n/app

Complaints - Rate per 10,000 occupied bed days 3 12.1 14.7 18.7 17.2

% staff appraised 49.9% 52.0% 57.4% n/app

1

2 Trajectory agreed with Clinical Commissioning Group (CCG).3

4

5

6

7

8

Percentage of staff who have an in date appraisal at month end.

Ou

tco

me

s M

etr

ics

TBC

1

TBC

Qu

alit

y G

ove

rna

nce

Ind

ica

tors

TBC

TBC

TBC

TBC

TBC

TBC

TBC

TBC

National Indicators / Quality Requirements - AF Quality and Governance

TDA Thresholds

CQ

C

Co

nce

rns

TBC

TBC

Meticillin Sensitive Staphylococcus Aureus (MSSA) cases 576

Data currently under review.

n/app

5

These figures show the number of full time equivalent (FTE) registered nurses (including midwives) as a proportion of all FTE nurses employed by the Trust at the end of each month.

TBC

For adult inpatients, A&E attenders and Maternity services.

Rate based on internal monthly overnight bed occupancy data.

Threshold not yet published by the TDA (although anticipated to be 0).

Figures shown for are based on snapshots of number of registered nurses (FTE) (excluding midwives) against the average number of available overnight General & Acute beds as reported in the

latest KH03 quarterly return.

n/app

TBC

2

7

Page 5 of 44

Shadow Monitor Risk Assessment Framework

Qrt 1 Qrt 2 Qrt 3 Qrt 4

(To date)

A&E Waiting Times (4 hours) - LTHT (including Wharfedale) *1 94.6% 97.9% 97.4% 95.2%

Patients treated within 18 weeks - admitted (%) *2 84.5% 84.4% 86.1% 87.2%

Patients treated within 18 weeks - non-admitted (%) *2 95.0% 94.7% 95.5% 95.2%

Patients awaiting treatment on the 18 weeks pathway - incomplete (%) *2 94.4% 94.9% 94.1% 95.2%

Cancer 2 week wait - suspected cancer 95.9% 93.0% 93.2% 87.0%

Cancer 2 week wait - breast symptoms (cancer not initially suspected) 94.4% 89.9% 91.3% 93.8%

Cancer 31 Day Waits - first definitive treatment 97.8% 96.7% 97.8% 96.2%

Cancer 31 Day Waits - subsequent surgery treatment 96.6% 97.9% 96.5% 94.3%

Cancer 31 Day Waits - subsequent anti-cancer drug regime treatment 99.8% 100% 100% 100%

Cancer 31 Day Waits - subsequent radiotherapy treatment course 99.0% 99.6% 96.0% 93.3%

Cancer 62 Day Waits - GP/Dentist referrals 85.1% 85.2% 80.5% 78.5%

Cancer 62 Day Waits - cancer screening service referrals 98.0% 95.3% 93.4% 100.0%

Q1 < 25 *3

51

76

Full year < 101

Compliance with requirements regarding access to healthcare for people with

learning disabilities (6 criteria)

Compliant on all 6

criteria

Compliant on all 6

criteria

Compliant on all 6

criteria

Compliant on all 6

criteria

3.0 3.0 4.0 4.0 4.0 4.0 5.0 5.0

*1

*2

*3

Weighted

score

A&E: 1 Jul to 29 Sep-13

CDI: Apr to Sep-13

RTT Incomplete:

As at 30 Sep-13

Other: Jul to Sep-13

0.0

1.0

1.0

0.0

1.0

0.0

0.0

95%

Weighted

score

A&E: 30 Sep to 29 Dec-13

CDI: Apr to Dec-13

RTT Incomplete:

As at 31 Dec-13

Other: Oct to Dec-13

1.0

Weighted

score

A&E: 30 Dec-13 to 09 Mar-14

CDI: Apr-13 to Feb-14

RTT Incomplete:

As at 28 Feb-14

Cancer: Jan-14

Other: Jan to Feb-14

0.00.0

Performance Indicator

National Indicators / Quality Requirements - Shadow Monitor Risk Assessment Framework (RAF) - Service Performance ScoreA

cce

ss M

etr

ics

92% 0.0

0.0

1.0

0.0

0.0

1.0

1.0

0.0

1.0

1.0

0.0

0.0

0.0

0.0

1.0

0.01.0

3.0

0.01.0

5.0

0.0

114 1.0 135 1.0

1.0

73

0.0

1.0

0.0

4.0

1.0

94%

90%1.0

0.0

Green

Risk Rating

93%1.0

93%

96%

Self certification

85%

94%

98%

0.0

General Notes

Failure to achieve any of the indicators with a weighting of 1 for three or more consecutive quarters may result in Monitor applying a governance concern and escalating the Trust for consideration as to whether it is in significant breach of its Foundation Trust

authorisation.

The CDI threshold used by Monitor is the greater of either: (a) a simple proportioning of the annual threshold (i.e. 25% of annual threshold at Q1, 50% at Q2 and 75% at Q3) or (b) 12 CDI cases.

A&E performance is derived from the weekly SITREP return figures. It should therefore be noted that the monthly and quarterly figures reported do not map directly to calendar months or quarters. Failure to meet this standard for any two quarters during the previous 12 month period and

failing the indicator again during the subsequent 9 month period or full year may trigger a governance concern.

Whilst the RAF monitors performance quarterly, any monthly failure of the RTT standards must be reported to Monitor and represents a failure of that indicator for the quarter.

Weighted

score

2013/14

Thresholds

Red

0.095%

90%

Weighting

A&E: 1 Apr to 30 Jun-13

RTT Incomplete:

As at 30 Jun-13

Other: Apr to Jun-13

1.0

0.0

4.0

1.0

1.0

1.0

1.0

Ou

tco

me

s

Ma

tric

s

Rating Criteria

Service Performance Score

< 4.0

> 4.0

CDI 1.0 41 1.0YTD (@ Q2) <

YTD (@ Q3) <

Page 6 of 44

Narrative

Referral To Treatment (RTT) Admitted Non-Admitted Incomplete Admitted Non-Admitted

> 90% > 95% > 92% > 90% > 95%

100.0% 99.9% 99.8% 89.8% 98.8%

97.8% 99.1% 99.0% 90.7% 98.8%

89.7% 85.1% 92.3% 96.9% 98.2%

89.2% 96.9% 96.7% 77.3% 95.9%

100.0% 100.0% 100.0% - 99.4%

98.5% 88.2% 73.3% 96.0% 96.9%

- 100.0% 100.0% 100.0% 100.0%

87.1% 96.8% 96.4% 81.9% 92.1%

92.2% 99.2% 99.0% 87.4% 91.9%

100.0% 99.7% 100.0% 100.0% 96.2%

77.8% 98.7% 97.2% 76.7% 93.9%

97.5% 99.1% 99.7% 86.9% 95.5%

100.0% 97.0% 96.2% 96.4% 96.0%

83.0% 81.9% 81.2% 79.2% 91.0%

100.0% 100.0% 100.0% 100.0% 99.4%

100.0% 99.8% 98.9% 100.0% 99.7%

82.2% 86.3% 93.4% 82.4% 89.7%

76.6% 92.6% 95.1% 77.0% 96.2%

83.2% 95.6% 96.1% 78.8% 96.3%

88.7% 95.5% 95.2% 85.4% 95.5%

Feb-14RTT Reporting Specialties

YTD

Urology

Cardiology

Cardiothoracic Surgery

Dermatology

Ear Nose & Throat

Elderly Medicine

Trust

Target

Oral Surgery

Other Specialties

Plastic Surgery

Respiratory Medicine

Rheumatology

Trauma & Orthopaedic

Gastroenterology

General Medicine

Gynaecology

Neurology

Neurosurgery

Ophthalmology

General Surgery

National Indicator / Quality Requirement

Aims:

Ensure at least 90% of admitted patients are treated within 18 weeks of referral.

Ensure at least 95% of non-admitted patients are treated within 18 weeks of referral.

Ensure a minimum of 92% of patients on an incomplete pathway have been waiting no more than 18 weeks.

Ensure no patients wait over 52 weeks from referral to treatment. Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graphs.

Actions:

Admitted: The Trust remains non-compliant with the admitted RTT target due to the continued focus on delivery of the agreed backlog clearance. Following further discussions with the IST and the TDA the rust has revised its position and agreed to deliver this target in June 2014 reported in July.The trust is currently ahead of the planned trajectory position and.

Non-admitted: Non-admitted performance continues to be achieved. Work continues with CSUs on delivering sustainable non-admitted waiting times, which are key to delivery of the Admitted RTT target.

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Ju

n-1

4

No

. o

f P

atie

nts

Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted

No. of Patients Trajectory Revised Trajectory

65%

70%

75%

80%

85%

90%

95%

100%

% o

f p

atie

nts

me

etin

g ta

rge

t

Trusts

% of Admitted Patients Seen Within 18 Weeks - April to December 2013

LTHT Peers Other Trusts Target

Source: NHS England

Page 7 of 44

Referral To Treatment (RTT) (Continued)

70%

75%

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% o

f p

atie

nts

me

etin

g ta

rge

t

% of Non-Admitted Patients Seen within 18 weeks

% Non-Admitted Achieve Fail

70%

75%

80%

85%

90%

95%

100%

% o

f p

atie

nts

me

etin

g ta

rge

t

Trusts


Source: NHS England

% of Non-Admitted Patients Seen Within 18 Weeks - April to December 2013

70%

75%

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% o

f p

atie

nts

me

etin

g ta

rge

t

% Incomplete Achieve Fail

% of Patients on an Incomplete Pathway Waiting no more than 18 Weeks

70%

75%

80%

85%

90%

95%

100%

% o

f p

atie

nts

me

etin

g ta

rge

t

Trusts


% of Patients on an Incomplete Pathway Waiting no More Than 18 Weeks - December 2013

Source: NHS England

0

5

10

15

20

25

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

No

. o

f p

atie

nts

Number of Patients Waiting Over 52 Weeks - Incomplete(As at month end)

Page 8 of 44

RTT Clearance Times

Total Clearance

Times

>18 wk

Clearance times

Incompletes

>18wks

8 Wks 0.5 Wks -

14.0 0.0 0.2%

7.7 0.1 1.7%

9.8 0.4 4.5%

5.5 0.6 11.3%

0.0 0.0 -

33.9 3.8 11.1%

- - -

9.6 0.7 7.8%

14.6 0.8 5.3%

52.0 0.0 0.0%

7.7 0.8 10.0%

8.9 0.1 0.9%

7.7 0.3 4.0%

6.2 1.8 28.5%

0.7 0.0 0.0%

6.3 0.0 0.0%

12.3 0.7 5.7%

16.7 1.5 9.0%

8.2 0.8 10.0%

9.7 0.7 7.6%Trust

Gynaecology

Neurology

Neurosurgery

Ophthalmology

Oral Surgery

Other Specialties

Plastic Surgery


Rheumatology

Trauma & Orthopaedic Surgery

Urology

General Medicine

Target

General Surgery

Cardiology

Cardiothoracic Surgery

Dermatology

Ear Nose & Throat

Elderly Medicine

Gastroenterology

RTT Reporting Specialties

Feb-14

Internal Indicator

Aims:

RTT clearance times aim to indicate how long, in weeks, it would take to clear current patients on incomplete pathways assuming that no new patients are added to the list. Although this is not a national target, a total clearance time of 8 weeks and an over 18 weeks clearance time of 0.5 weeks is deemed to indicate a sustainable waiting list according to the Department of Health (DH).

Reduce the number of patients waiting over 18 weeks at month-end (incomplete admitted) to 714 by the end of March 2014.

Owner: Chief Operating Officer and Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.

Actions:

Total: Total RTT clearance times have risen to 9.7 for February from 8.6 in January. The aim remains to achieve an 8 week standard through delivery of the revised CSU trajectories for OP waits and over 18 week Admitted clearance.

Over 18 weeks: Over 18 week RTT clearance times have remained at 0.7 weeks, against the 0.5 week internal target. It is expected that this standard will be delivered alongside the achievement of the 18 week admitted target in June 2014, in line with the revised CSU trajectories.

0

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18

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n-1

4

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b-1

4

Cle

ara

nce

Tim

es

Referral to Treatment - Clearance Times

Total Clearance Times >18 wk Clearance Times

Total Clearance Times Target >18 wk Clearance Times Target

0

100

200

300

400

500

600

700

800

0 1 2 3 4 5 6 7 8 9

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49

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51

52+

Unkn

ow

n

No

. o

f P

atie

nts

Weeks Waiting

Number of Patients Waiting on an Incomplete Admitted Pathway - By TimebandComparison between April 2013 and February 2014

Apr-13 Feb-14

Page 9 of 44

Diagnostic Waits

Number of

Patients on

Waiting List

Number

Waiting over 6

Weeks

% Waiting

Less Than 6

Weeks

Target - - 99%

Audiology - Audiology Assessments 0 0 -

Barium Enema 3 0 100.0%

Cardiology - echocardiography 891 0 100.0%

Cardiology - electrophysiology 0 0 -

Colonoscopy 526 33 93.7%

Computed Tomography 1,471 0 100.0%

Cystoscopy 307 3 99.0%

DEXA Scan 569 1 99.8%

Flexi sigmoidoscopy 316 17 94.6%

Gastroscopy 607 28 95.4%

Magnetic Resonance Imaging 2,095 5 99.8%

Neurophysiology - peripheral neurophysiology 0 0 -

Non-obstetric ultrasound 4,647 0 100.0%

Respiratory physiology - sleep studies 113 0 100.0%

Urodynamics - pressures & flows 0 0 -

Trust 11,545 87 99.2%

Diagnostic Test

Waiting List Position As at 28/02/2014


Aim: Ensure at least 99% of patients wait no more than 6 weeks for a diagnostic test. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, timely access to treatment, quality of care, reputation & financial penalty.

Appendix 2 lists the peer Trusts included in the benchmarking graphs.

90%

92%

94%

96%

98%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% P

atie

nts

Wa

itin

g L

ess T

ha

n 6

we

eks

% Within 6 Weeks Target

Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-End

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000A

pr-

12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

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g-1

2

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p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

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r-13

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r-13

Ma

y-1

3

Ju

n-1

3

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l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

No

. o

f p

atie

nts

wa

itin

g

Diagnostic Waits - Number of Patients Waiting for a Diagnostic Test at Month-End

70%

75%

80%

85%

90%

95%

100%

% P

atie

nts

Wa

itin

g L

ess T

ha

n 6

we

eks

Trusts


Source: NHS England

Diagnostic Waits - % Patients Waiting Less Than 6 Weeks at Month-EndJanuary 2014

Page 10 of 44

Cancelled Operations

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 Q2 Q3 Q4 Q1 Q2 Q3

% la

st m

inu

te c

an

ce

lla

tio

ns

% of Last Minute Cancelled Operations for Non-Clinical Reasons

2012/13 2013/14


Internal Indicator

Aims:

Ensure all patients who have operations cancelled at the last minute, for non-clinical reasons are offered another binding date to be treated within a maximum of 28 days.

Ensure no patient has their urgent operation cancelled for a second time. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalties.

Appendix 2 lists the peer Trusts included in the benchmarking graph.

Actions:

The quarter 3 position against the indicator for cancelled operations not rebooked within 28 days demonstrated significant improvement on quarter 2 performance, and focus continues on reducing such breaches in Q4 (recognising the impact of winter pressures).

Root cause analyses of all Q3 and January breaches have been returned and are being analysed for themes to support further reductions in Q4.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

% p

atie

nts

bre

ach

ing

targ

et

Trusts

% Patients Not Treated Within 28 Days of Last Minute Cancellation for Non-Clinical Reasons - Q3 2013-14

LTHT Peers Other Trusts

Source: NHS England(NB: 75 Trusts reported no breaches, including 4 peer Trusts)

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 Q2 Q3 Q4 Q1 Q2 Q3

% p

atie

nts

bre

ach

ing

targ

et

Patients Cancelled at Last Minute for Non-Clinical Reasons: % Not Treated Within 28 Days

% 28 Day Breaches Achieve Fail

2012/13 2013/14

Page 11 of 44

A&E Waiting Times (4 Hours)

Indicator Site Feb-14 YTD

St James's 6,771 79,125

LGI 8,978 102,548

Wharfedale 1,503 20,441

Trust 17,252 202,114

St James's 729 4,604

LGI 321 2,751

Wharfedale 0 0

Trust 1,050 7,355

St James's 89.2% 94.2%

LGI 96.4% 97.3%

Wharfedale 100% 100%

Trust 93.9% 96.4%

Target

A&E: Number of Attendances n/app

A&E: Performance > 95%

A&E: Number of Breaches n/app


Aim: Ensure at least 95% of A&E attendances are admitted, transferred or discharged within 4 hours of arrival. Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graph.

Actions:

Departmental outflow is being closely managed through daily operational planning and Silver Command meetings.

Daily breach reviews are also being undertaken.

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

07/0

4/2

013

14/0

4/2

013

21/0

4/2

013

28/0

4/2

013

05/0

5/2

013

12/0

5/2

013

19/0

5/2

013

26/0

5/2

013

02/0

6/2

013

09/0

6/2

013

16/0

6/2

013

23/0

6/2

013

30/0

6/2

013

07/0

7/2

013

14/0

7/2

013

21/0

7/2

013

28/0

7/2

013

04/0

8/2

013

11/0

8/2

013

18/0

8/2

013

25/0

8/2

013

01/0

9/2

013

08/0

9/2

013

15/0

9/2

013

22/0

9/2

013

29/0

9/2

013

06/1

0/2

013

13/1

0/2

013

20/1

0/2

013

27/1

0/2

013

03/1

1/2

013

10/1

1/2

013

17/1

1/2

013

24/1

1/2

013

01/1

2/2

013

08/1

2/2

013

15/1

2/2

013

22/1

2/2

013

29/1

2/2

013

05/0

1/2

014

12/0

1/2

014

19/0

1/2

014

26/0

1/2

014

02/0

2/2

014

09/0

2/2

014

16/0

2/2

014

23/0

2/2

014

02/0

3/2

014

09/0

3/2

014

16/0

3/2

014

% p

atie

nts

me

etin

g ta

rge

t

Week

A&E - 2012/13 and 2013/14 Performance Against the 4 Hour Access Standard (Including Wharfedale)

Standard 12/13 Performance 13/14 Performance

Page 12 of 44

A&E Measures

Indicator Site Feb-14 YTD

St James's 0 0

LGI 0 0

Trust 0 0

St James's 12 14

LGI 17 17

Trust 16 15

St James's 97 88

LGI 75 71

Trust 84 78

St James's 9.6% 9.9%

LGI 6.9% 6.4%

Trust 8.0% 7.9%

St James's 4.4% 4.1%

LGI 3.0% 2.7%

Trust 3.6% 3.3%

0

Target

A&E: % Unplanned Re-

Attendances Within 7 Days

A&E: % Patients Leaving A&E

Unseen

< 15

< 60

A&E: Time to Assessment

(95th Percentile)

A&E: Time to Treatment

(median)

< 5%

< 5%

A&E: Number of Trolley Waits

Greater Than 12 Hours

Local Contractual Indicator

Internal Indicator

Aims:

Ensure there are no A&E trolley waits greater than 12 hours.

Ensure 95th percentile for time of arrival at A&E to initial full assessment is no more than 15 minutes.

Ensure the median time spent from arrival at A&E to treatment is no more than 60 minutes.

Ensure the percentage of unplanned re-attendances within 7 days of discharge from A&E is no more than 5%.

Ensure percentage of patients who leave A&E without being seen is no more than 5%.

Owner: Chief Operating Officer and Clinical Director of Urgent Care. Consequence of failure: Patient experience, clinical outcomes, timely access to treatment, reputation & financial penalty.

0

5

10

15

20

25

Ap

r-12

Ma

y-1

2

Ju

n-1

2

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l-1

2

Au

g-1

2

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p-1

2

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12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

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r-13

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r-13

Ma

y-1

3

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n-1

3

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l-1

3

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g-1

3

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p-1

3

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3

Dec-1

3

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n-1

4

Fe

b-1

4

Tim

e to

Asse

ssm

en

t (m

ins)

A&E - Time To Assessment - 95th Percentile

Time To Assessment - 95th Percentile Target

0

20

40

60

80

100

120

Ap

r-12

Ma

y-1

2

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n-1

2

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l-1

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g-1

2

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p-1

2

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2

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n-1

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r-13

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3

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g-1

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p-1

3

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3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

Tim

e to

Tre

atm

en

t (m

ins)

A&E - Time to Treatment - Median

Time To Treatment - Median Target

Page 13 of 44

A&E Measures (Continued)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% U

np

lan

ne

d R

ea

tte

nd

an

ce

s

A&E - Unplanned Re-Attendances Within 7 Days

Unplanned Re-Attendances Within 7 days Target

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% P

atie

nts

Le

avin

g A

&E

Un

se

en

A&E - Patients Leaving A&E Unseen

Patients Leaving A&E Unseen Target

Page 14 of 44

Cancer 62 Days

Tumour Type Jan-14 (%)

Breast 100.0%

Gynaecological 55.2%

Haematological (Excluding Acute Leukaemia) 88.0%

Head & Neck 68.4%

Lower Gastrointestinal 84.8%

Lung 57.6%

Other 50.0%

Sarcoma 100.0%

Skin 100.0%

Upper Gastrointestinal 82.8%

Urological (Excluding Testicular) 67.1%

Trust 78.5%

Cancer 62 Day Waits - Screening Referrals 100.0%

Cancer 62 Day Waits - Consultant Upgrades (local contractual indicator) 66.7%

Cancer 62 Day Waits - GP Referral



Aims:

Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days following an urgent GP (GDP or GMP) referral for suspected cancer.

Ensure at least 90% of patients receive their first definitive treatment for cancer within 62 days following referral from an NHS cancer screening service.

Ensure at least 85% of patients receive their first definitive treatment for cancer within 62 days of a consultant decision to upgrade their priority status (local contractual indicator).

Owner: Chief Operating Officer and Clinical Director of Leeds Cancer Centre. Consequence of failure: Timely access to treatment, patient experience, clinical outcomes, reputation & financial penalty.

Appendix 2 lists the peer Trusts included in the benchmarking graphs.

The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline. Performance against the 62 day standard for referrals from consultant upgrade are liable to fluctuate due to the small numbers involved.

Actions:

Capacity issues in Gynaecology and Urology, as well as delays in Pathology turnaround, remain concerns. Additional lists are in place in Gynaecology and Urology, and the backlog is being addressed, but will not deliver sustainable performance until Q1 2014/15. A Pathology recovery plan is to be presented by the end of March.

The late referral of patients (past day 38) from other organisations remains a concern. A request via the Chief Operating Officer and Commissioners to ensure timely referrals is now being further supported through meetings between the Trust Lead Cancer team and referring cancer teams in Q4. The Trust will continue to fail this standard in February and March, with action plans aiming to restore performance for Q1 2014/15.

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

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p-1

2

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12

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2

Dec-1

2

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n-1

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b-1

3

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r-13

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r-13

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y-1

3

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n-1

3

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l-1

3

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g-1

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p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals

% Within 62 Days - GP/Dentist Target

40%

60%

80%

100%

Bre

ast

Gynaec

olo

gic

al

Haem

ato

logic

al (

Exc

ludin

gA

cute

Leuka

em

ia)

Head &

Neck

Low

er G

astroin

testin

al

Lung

Oth

er

Sarc

om

a

Ski

n

Upper G

astroin

testin

al

Uro

logic

al (

Exc

ludin

gT

estic

ula

r)

% p

atie

nts

me

etin

g ta

rge

t

Cancer 62 Day Waits for GP Referrals by Tumour Type - Jan 2014

Performance Target

Page 15 of 44

Cancer 62 Days (Continued)

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

62 Day Upgrade 62 Day Upgrade Target

Performance Against the 62 Day Cancer Standard for Referrals from Consultant Upgrade

NB. Due to the small numbers involved, the above data are liable to fluctuate. In January 2014, for instance, 3 of just 4.5 accountable cases were treated within 62 days.

40%

50%

60%

70%

80%

90%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

62 Day Screening 62 Day Screening Target

Performance Against the 62 Day Cancer Standard for Referrals from Screening Service

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% W

ith

in 6

2 D

ays

Trusts

Performance Against the 62 Day Cancer Standard for GP/Dentist Referrals - 2013-14 Q3


Source: NHS England

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% W

ith

in 6

2 D

ays

Trusts

Performance Against the 62 Day Cancer Standard for Referrals from Screening Service - 2013-14 Q3


Source: NHS England

Page 16 of 44

Cancer 31 Days Tumour Type Jan-14 (%)

Brain/Central Nervous System 100.0%

Breast 100.0%

Children's 100.0%

Gynaecological 100.0%

Haematological 100.0%

Head & Neck 82.6%

Lower Gastrointestinal 95.0%

Lung 94.4%

Sarcoma 85.7%

Skin 96.2%

Upper Gastrointestinal 100.0%

Urological 94.5%

Other 100.0%

Trust 96.2%

Cancer 31 Day Waits - Subsequent Surgery 94.3%

Cancer 31 Day Waits - Subsequent Drug Treatment 100.0%

Cancer 31 Day Waits - Subsequent Radiotherapy 93.3%

Cancer 31 Day Waits - First Definitive Treatment


Aims:

Ensure at least 96% of patients receiving their first definitive treatment are treated within 31 days.

Ensure at least 94% of patients receiving subsequent surgery are treated within 31 days.

Ensure at least 98% of patients receiving a subsequent anti-cancer drug regimen are treated within 31 days.

Ensure at least 94% of patients receiving subsequent radiotherapy are treated within 31 days.


The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.

Actions:

Although overall compliance was achieved for Q3, the Trust failed the 31 day target for Subsequent Radiotherapy for both December and January; the main cause was an unexpected rise in demand at the same time as a planned machine upgrade.

The Trust is expecting to achieve the standard for Q4, with additional sessions and staff having been put in place in the short term to address the backlog.

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

% Within 31 Days - First Treatments Target

Performance Against the 31 Day Cancer Standard for First Treatments

80%

85%

90%

95%

100%

Bra

in/C

ent

ral N

erv

ous

Sys

tem

Bre

ast

Child

ren's

Gynaec

olo

gic

al

Haem

ato

logic

al

Head &

Neck

Low

er G

astroin

testin

al

Lung

Sarc

om

a

Ski

n

Upper G

astroin

testin

al

Uro

logic

al

Oth

er

% p

atie

nts

me

etin

g ta

rge

t

Performance Target

Cancer 31 Day Waits for First Definitive Treatment by Tumour Type - Jan 2014

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

Drug Drug Target

Surgery Surgery and Radiotherapy Target

Radiotherapy

Performance Against the 31 Day Cancer Standard for Second or Subsequent Treatment

Page 17 of 44

Cancer 2 Week Wait

Tumour Type Jan-14 (%)

Suspected brain/central nervous system tumours 90.9%

Suspected breast cancer 97.4%

Suspected children's cancer 78.6%

Suspected gynaecological cancer 90.7%

Suspected haematological malignancies (excluding acute leukaemia) 92.9%

Suspected head & neck cancer 72.6%

Suspected lower gastrointestinal cancer 87.5%

Suspected lung cancer 100.0%

Suspected sarcoma 100.0%

Suspected skin cancer 76.8%

Suspected testicular cancer 94.7%

Suspected upper gastrointestinal cancer 93.3%

Suspected urological malignancies (excluding testicular) 96.7%

Trust 87.0%

Cancer 2 Week Waits - Breast Symptoms 93.8%

Cancer 2 Week Waits - Suspected


Aims:

Ensure at least 93% of patients urgently referred with suspected cancer by their GP (GMP or GDP) are seen within 14 days.

Ensure at least 93% of patients urgently referred for evaluation/investigation of “breast symptoms” by a primary or secondary care professional are seen within 14 days.


The cancer indicators are monitored a month in arrears due to the timing of the national reporting deadline.

Actions:

The Trust failed this standard in January and due to the scale of the problem in that month will fail the standard for Q4 2013/14. Action plans are in place for the Dermatology and Breast services in particular and the standard is being achieved in February and so far in March, but will not recover the overall position for the quarter.

Breast symptoms: This standard was met in January and is expected to achieve overall for Q4, due to the recovery plan in place for additional Radiology capacity as well as Breast Surgery clinic capacity.

80%

85%

90%

95%

100%

Ap

r-12

Ma

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2

Ju

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2

Ju

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2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

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3

Ma

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r-13

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y-1

3

Ju

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3

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Se

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Oct-

13

Nov-1

3

Dec-1

3

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4

% p

atie

nts

me

etin

g ta

rge

t

% Within 14 Days - Suspected Cancer Target

Performance Against the 2 Week Cancer Standard for Suspected Cancer

80%

85%

90%

95%

100%

Susp

ecte

d b

rain

/centr

al

nerv

ous

syst

em

tum

ours

Susp

ecte

d b

reast

cancer

Susp

ecte

d c

hild

ren's

cancer

Susp

ecte

d g

ynaec

olo

gic

al

cancer

Susp

ecte

d h

aem

ato

logic

al

malig

nancie

s (e

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din

g

acu

te le

ukaem

ia)

Susp

ecte

d h

ead &

neck

cancer

Susp

ecte

d low

er

gast

roin

test

inal ca

nce

r

Susp

ecte

d lung c

ance

r

Susp

ecte

d s

arc

oma

Susp

ecte

d s

kin c

ance

r

Susp

ecte

d testic

ula

rca

ncer

Susp

ecte

d u

pper

gast

roin

test

inal ca

nce

r

Susp

ecte

d u

rolo

gic

al

malig

nancie

s (e

xclu

din

g

test

icula

r)

% p

atie

nts

me

etin

g ta

rge

t

Cancer 2 Week Waits for Suspected Cancer by Tumour Type - Jan 2014

Performance Target

80%

85%

90%

95%

100%

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% Within 14 Days - Breast Symptoms Target

Performance Against the 2 Week Cancer Standard for Breast Symptoms

Page 18 of 44

Stroke Care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

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3

Ja

n-1

4

% w

ith

in 2

4 h

ou

rs

Proportion of High-Risk TIA Patients Investigated and Treated within 24 Hours of First Contact with a Health Professional

Internal Indicator

Aims:

Ensure at least 80% of patients who have had a stroke spend at least 90% of their time in hospital on a stroke unit.

Ensure high-risk TIA patients are investigated and treated within 24 hours of first contact with a health professional.

Owner: Chief Operating Officer and Clinical Director of the Centre for Neurosciences Consequence of failure: Timely access to treatment, patient experience, clinical outcomes & financial penalty.

The Stroke and TIA indicators are monitored a month in arrears.

Actions:

Provisional data indicates that February performance against the 80% Stroke care threshold has been restored.

Further work is on-going to ensure all accountable patients are captured in the numerator for this indicator.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

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2

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Stroke Discharges Spending at Least 90% of Spell on a Stroke Unit

90% of spell on stroke unit Target

Page 19 of 44

30 Day Emergency Readmissions

ElectiveNon-

ElectiveTotal Elective

Non-

ElectiveTotal Elective Non-Elective Total

Acute Medicine 1.0% 18.2% 16.2% 2.0% 18.8% 16.8% 4.0% 14.2% 12.7%

Adult Critical Care - 0.0% 0.0% - 5.9% 5.9% 2.0% 4.4% 2.2%

Adult Theatres & Anaesthesia 0.0% - 0.0% 0.0% - 0.0% 3.6% 8.6% 4.9%

Cardio-Respiratory 3.0% 16.0% 10.8% 3.6% 14.9% 10.2% 5.5% 15.5% 10.4%

Centre for Neurosciences 2.6% 8.0% 4.4% 2.7% 8.4% 4.6% 3.8% 10.7% 6.2%

Chapel Allerton Hospital 2.2% 7.1% 2.3% 1.7% 13.3% 1.9% 2.3% 11.2% 2.4%

Childrens 4.4% 5.5% 5.0% 4.5% 5.8% 5.3% 6.4% 9.7% 7.9%

Digestive Diseases 3.0% 17.3% 7.2% 3.5% 16.0% 7.2% 4.1% 14.5% 7.0%

Head & Neck 2.0% 9.7% 2.9% 2.2% 6.8% 2.7% 2.9% 6.8% 3.6%

Hepatorenal 4.5% 15.1% 7.3% 4.3% 15.6% 7.3% 5.9% 17.8% 8.6%

Leeds Cancer Centre - - - - - - 7.7% 19.3% 9.1%

Leeds Dental Institute 0.0% - 0.0% 0.3% 0.0% 0.3% 0.9% 1.6% 1.0%

Pathology - - - 0.0% - 0.0% 0.0% 0.0% 0.0%

Radiology - - - - - - 5.2% 10.6% 5.4%

Trauma and Related Services 2.2% 8.1% 4.4% 2.9% 8.3% 5.1% 3.7% 8.1% 5.7%

Urgent Care - 11.2% 11.2% - 10.9% 10.9% 3.0% 11.4% 11.4%

Womens 2.2% 1.8% 1.8% 2.0% 1.2% 1.3% 2.7% 2.3% 2.4%

Trust 3.6% 11.3% 6.8% 3.8% 11.0% 6.9% 4.7% 11.0% 7.2%

(NB: RAG ratings are based on thresholds set by the TDA)

CSU

Jan-14 YTD Total Peer - Feb-12 to Jan-13


Aim: Ensure no more than 10.9% of patients are readmitted as an emergency within 30 days of discharge, following elective or non-elective treatment. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, quality of care, reputation & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graphs.

0%

2%

4%

6%

8%

10%

12%

14%

Ap

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Ma

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2

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2

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g-1

2

Se

p-1

2

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Nov-1

2

Dec-1

2

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Nov-1

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Ja

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% R

ea

dm

issio

ns

Readmissions - Elective

% Readmissions Peer % Readmissions

0%

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Oct-

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Nov-1

3

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n-1

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% R

ea

dm

issio

ns

Readmissions - Non-Elective


0%

2%

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6%

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Ap

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g-1

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Se

p-1

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Oct-

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Nov-1

2

Dec-1

2

Ja

n-1

3

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b-1

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r-13

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y-1

3

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n-1

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g-1

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p-1

3

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% R

ea

dm

issio

ns

Readmissions - Total (Elective and Non-Elective)


Page 20 of 44

Outpatient Activity - New and Review

Plan Activity Variance Plan Activity Variance

Acute Medicine 1,908 1,737 -171 22,231 19,971 -2,260

Adult Critical Care 0 0 0 0 1 1

Adult Theatres & Anaesthesia 21 95 74 246 1,344 1,098

Adult Therapies 1 3,556 2,930 -626 41,425 42,650 1,225

Cardio-Respiratory 3,131 3,382 251 36,479 38,552 2,073

Centre for Neurosciences 1,831 1,959 128 21,282 23,928 2,646

Chapel Allerton Hospital 6,359 6,729 370 73,493 74,974 1,481

Childrens 2,853 3,000 147 32,781 35,209 2,428

Digestive Diseases 3,147 2,544 -603 34,502 29,572 -4,930

Head & Neck 7,260 7,824 564 83,293 85,001 1,708

Hepatorenal 4,140 4,834 694 48,229 47,871 -358

Institute of Oncology 8,837 8,864 27 101,498 96,047 -5,451

Leeds Dental Institute 3,238 3,396 158 37,529 35,182 -2,347

Pathology 1 0 -1 9 8 -1

Radiology 850 2,013 1,163 9,904 21,669 11,765

Trauma and Related Services 4,179 4,108 -71 48,613 46,906 -1,707

Urgent Care 2 2,138 - -2,138 24,911 21,151 -3,760

Womens 1,702 2,223 521 19,823 19,504 -319

Trust 55,151 55,638 487 636,248 639,540 3,292

CSUFeb-14 YTD

Outpatient Activity - Review Attendances

Internal Indicator

Aim: Maintain financial viability through delivery of planned activity. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

New:

Overall Trust activity year to-February was 2% below plan.

Year-to-February, the following CSUs were more than 10% below their plan: Digestive Diseases, and the Institute of Oncology (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers, and Urgent Care – as explained in footnote 2 below).

Review:

Overall Trust activity year to-February was 0.5% above plan.

Year-to-February, the following CSUs were more than 10% below their plan: Acute Medicine and Digestive Diseases (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers, and Urgent Care – as explained in footnote 2 below).


Acute Medicine 380 457 77 4,427 5,222 795

Adult Critical Care 4 6 2 47 41 -6

Adult Theatres & Anaesthesia 0 0 0 0 2 2

Adult Therapies 1 1,376 1,226 -150 16,036 17,675 1,639

Cardio-Respiratory 1,844 1,838 -6 21,483 21,432 -51

Centre for Neurosciences 1,538 1,374 -164 17,816 16,958 -858

Chapel Allerton Hospital 1,935 1,937 2 22,243 21,837 -406

Childrens 1,184 1,200 16 13,544 13,793 249


Head & Neck 2,734 4,212 1,478 31,278 30,917 -361

Hepatorenal 887 1,059 172 10,332 11,599 1,267

Institute of Oncology 1,907 1,974 67 21,749 18,837 -2,912

Leeds Dental Institute 1,085 1,250 165 12,969 13,247 278

Pathology 3 0 -3 31 31 0

Radiology 260 421 161 3,027 4,398 1,371

Trauma and Related Services 2,111 2,098 -13 24,464 24,344 -120

Urgent Care 2 1,785 - -1,785 20,795 17,559 -3,236

Womens 1,094 1,454 360 12,740 13,701 961

Trust 21,573 21,548 -25 249,227 244,331 -4,896

Outpatient Activity - New Attendances

CSUFeb-14 YTD

1 Activity for Psychology (within the Adult Therapies CSU) is not included for the reporting month in the above data. 2 Urgent Care activity for the reporting month is not included in the above data.

Page 21 of 44

Inpatient Activity - Elective and Non-elective


Acute Medicine 1,458 1,355 -103 17,397 15,733 -1,664

Adult Critical Care 5 8 3 61 71 10


Adult Therapies 0 0 0 0 0 0

Cardio-Respiratory 718 824 106 8,568 8,550 -18

Centre for Neurosciences 316 237 -79 3,766 2,770 -996

Chapel Allerton Hospital 17 12 -5 197 156 -41

Childrens 651 664 13 7,771 7,658 -113

Digestive Diseases 607 610 3 7,245 7,526 281

Head & Neck 137 168 31 1,637 1,769 132

Hepatorenal 329 272 -57 3,921 3,851 -70

Institute of Oncology 318 311 -7 3,795 3,905 110

Leeds Dental Institute 0 0 0 2 5 3

Pathology 0 0 0 0 1 1

Radiology 13 11 -2 150 197 47

Trauma and Related Services 427 442 15 5,098 5,383 285

Urgent Care 972 674 -298 11,598 8,521 -3,077

Womens 124 90 -34 1,482 1,359 -123

Awaiting CSU Allocation 0 0 0 0 5 5

Trust 6,092 5,678 -414 72,690 67,460 -5,230

CSUFeb-14 YTD

Inpatient Activity - Non-Elective (Spells)

Internal Indicator

Aim: Maintain financial viability through delivery of planned activity Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

Elective:

Overall Trust activity year to-February was 0.3% below plan.

Year-to-February, only the Radiology CSU was more than 10% below its plan (this excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers).

Non-elective:

Overall Trust activity year to-February was 7.2% below plan.

Year-to-February, the following CSUs were more than 10% below their plan: Centre for Neurosciences, Chapel Allerton Hospital, and Urgent Care (this list excludes any CSU where the plan was for less than 100 attendances and the CSU variance from plan involved only small numbers).


Acute Medicine 185 170 -15 2,156 2,039 -117

Adult Critical Care 0 0 0 2 0 -2


Adult Therapies 0 0 0 0 0 0

Cardio-Respiratory 505 495 -10 5,879 5,940 61

Centre for Neurosciences 561 520 -41 6,320 5,997 -323

Chapel Allerton Hospital 939 827 -112 10,911 10,278 -633

Childrens 846 861 15 9,632 10,553 921


Head & Neck 1,090 1,078 -12 12,501 12,671 170

Hepatorenal 879 940 61 9,986 10,922 936

Institute of Oncology 2,374 2,406 32 27,489 28,336 847

Leeds Dental Institute 130 134 4 1,527 1,469 -58

Pathology 0 0 0 0 1 1

Radiology 13 13 0 157 134 -23

Trauma and Related Services 691 654 -37 7,697 7,505 -192

Urgent Care 0 0 0 3 0 -3

Womens 281 217 -64 3,282 3,079 -203

Trust 10,429 9,802 -627 117,536 117,166 -370

Inpatient Activity - Elective (Spells)

CSUFeb-14 YTD

Page 22 of 44

Length of Stay

0

2

4

6

8

10

12

14

16

Ophth

alm

olo

gy

Gynaec

olo

gy

Ora

l Surg

ery

Ear

Nose

& T

hro

at

Pla

stic

Surg

ery

Card

iolo

gy

Uro

logy

Rheum

ato

logy

Derm

ato

logy

Tra

um

a &

Ort

hop

aedic

Surg

ery

Genera

l Medic

ine

Gastroente

rolo

gy

Genera

l Surg

ery

Neuro

logy

Neuro

surg

ery

Resp

irato

ry M

edic

ine

Eld

erly M

edic

ine

Le

ng

th o

f S

tay

LTHT Peer Average

For peer listing, please see Appendix 2 Source: Dr Foster

Length of Stay: Selected Specialties Jan 13 to Dec-13

Internal Indicator

Aim: To reduce the length of stay in order to release capacity for other patients and provide an improved patient experience. Owner: Chief Operating Officer and CSU Clinical Directors. Consequence of failure: Patient experience, financial and clinical outcomes.

\

Specialty LTHT Peer Avg

Ophthalmology 0.8 1.6

Gynaecology 1.6 1.6

Oral Surgery 2.1 2.1

Ear Nose & Throat 2.5 2.6

Plastic Surgery 2.6 2.7

Cardiology 3.2 4.4

Urology 3.8 3.2

Rheumatology 4.3 5.7

Dermatology 4.8 6.3

Trauma & Orthopaedic Surgery 4.9 4.6

General Medicine 6.8 6.1

Gastroenterology 7.4 8.1

General Surgery 7.5 6.7

Neurology 9.5 9.2

Neurosurgery 10.5 8.1

Respiratory Medicine 10.5 7.6

Elderly Medicine 11.5 13.6

All Specialties 5.1 4.8

Length of Stay: Selected Specialties

Jan-13 to Dec-13

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

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Nov-1

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Le

ng

th o

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tay

Length of Stay: Trust Level - Jan-13 to Dec-13

Length of Stay Expected Length of Stay

Source: Dr Foster

Page 23 of 44

Incidence of MRSA

By CSU Feb-14 YTD

Acute Medicine 0 1

Centre for Neurosciences 0 1

Digestive Diseases 0 2

Leeds Cancer Centre 0 2

Trust 0 6


Aim: Eliminate Trust-apportioned MRSA bacteraemia cases in 2013/14. Owner: Chief Medical Officer, Infection Control Team, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.


As at 14th February, no MRSA bacteraemias had been provisionally recorded for

February 2014. Actions:

A process to ensure clinical teams are able to rapidly identify Mupirocin resistance in MRSA-positive patients is currently being put in place.

By month

MRSA Cases

(Trust-

Apportioned)

Achieve

Trajectory

( < )

Apr-13 1 0

May-13 2 0

Jun-13 0 0

Jul-13 0 0

Aug-13 1 0

Sep-13 1 0

Oct-13 0 0

Nov-13 0 0

Dec-13 0 0

Jan-14 1 0

Feb-14 0 0

0

1

2

3

4

5

6

7

8

9

Ca

se

s P

er

10

0,0

00

Occu

pie

d B

ed

Da

ys

Trusts

Number of MRSA Bacteraemia Cases Per 100,000 Occupied Bed Days (Trust Apportioned) - April 2013 to January 2014


Source: HPA(NB: 36 Trusts reported no MRSA cases for the period, including 2 peer Trusts)

Page 24 of 44

MRSA Screening

Target > 95% > 95%

CSU Feb-14 YTD

Acute Medicine 97.1% 96.9%

Adult Critical Care 98.9% 96.3%

Adult Theatres & Anaesthesia 98.1% 96.9%

Cardio-Respiratory 96.3% 95.5%

Centre for Neurosciences 98.5% 97.5%

Chapel Allerton Hospital 99.7% 98.0%

Children's 91.0% 90.8%

Digestive Diseases 96.4% 96.3%

Head & Neck 94.4% 92.6%

Hepatorenal 99.3% 97.4%

Leeds Cancer Centre 94.9% 95.8%

Leeds Dental Institute * No eligible patients 11.1%

Trauma & Related Services 90.0% 91.3%

Urgent Care 95.2% 92.7%

Women's 97.0% 95.5%

Trust 96.1% 95.7%

* Low numbers of eligible patients

MRSA Screening - % of Eligible Patients Screened


Aim: Ensure that at least 95% of eligible admitted patients are screened for MRSA. Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes & financial penalty.

80%

85%

90%

95%

100%

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en

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MRSA Screening (Elective and Non Elective Admissions)

% Screened Target

Page 25 of 44

Incidence of CDI

By CSU Feb-14 YTD

Acute Medicine 5 34

Adult Critical Care 0 11

Cardio-Respiratory 0 12

Centre for Neurosciences 0 8

Children's 1 16

Digestive Diseases 1 19

Head & Neck 0 1

Hepatorenal 1 14

Leeds Cancer Centre 1 12

Trauma & Related Services 0 7

Women's 0 1

Trust 9 135

CDI Rate per 100,000 Bed Days 18.3 23.8

CDI



Aims:

Reduce the number of Trust-attributed CDIs in 2013/14 to no more than 101.

Reduce the CDI rate per 100,000 occupied bed days in line with the NHS Standard Contract.

Owner: Chief Medical Officer, CSU Clinical Directors Consequence of failure: Patient safety, patient experience, quality of care, clinical outcomes, reputation & financial penalty.


As at 14th February, 4 CDIs had been recorded for February 2014.

Actions:

Executive-led CDI review meetings with CSUs continue to take place.

A new root cause analysis investigation tool has been introduced.

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Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

No

. C

DI ca

se

s

Progress Against the CDI Target (Cumulative)

CDI Cases Achieve Trajectory

0

5

10

15

20

25

30

35

40

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

CD

I R

ate

Pe

r 1

00

,00

0 O

ccu

pie

d B

ed

Da

ys

CDI Rate Per 100,000 Occupied Bed Days

NB: Denominator taken from internal Midnight Bed State data

0

5

10

15

20

25

30

35

40

Ca

se

s p

er

10

0,0

00

Occu

pie

d B

ed

Da

ys

Trusts

Number of C.Difficile Cases Per 100,000 Occupied Bed Days for Patients Aged > 2 Years (Trust Apportioned) - April 2013 to January 2014


Source: HPA(NB: 4 Trusts reported no CDI cases for the period)

Page 26 of 44

Summary Hospital Mortality Index (SHMI)

SHMI Measure Spells SHMIObserved

Deaths

Expected

Deaths

95%

Confidence

Interval

SHMI 95% CI 126278 95.15 3982 4185 92.21-98.15

SHMI (adjusted for palliative care) 126278 96.93 3982 4108 93.95-99.99

SHMI (in hospital deaths) 126278 93.16 2824 3031 89.76-96.67

Trust Level SHMI (with adjustments) for July 2012 to June 2013


The SHMI reports mortality at Trust level across the NHS in England using standard and transparent methodology. SHMI is the nationally recognised hospital level indicator of mortality. Aim: Improve SHMI rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.

The Trust SHMI (source: Dr Foster) for the latest available period, July 2012 to June 2013, was 95.15 - better than expected. Relative Risk mortality was either within or better than the expected range for all Clinical Classification System (CCS) groups for in hospital deaths over the same period. The Trust has consistently maintained an overall SHMI within or better than the expected range over the latest available 3 year period.

Page 27 of 44

Hospital Standardised Mortality Rate (HSMR)

Measure Spells HSMRObserved

Deaths

Expected

Deaths

95%

Confidence

Interval

HSMR 59047 91.17 2412 2646 87.56-94.88

Trust Level HSMR for July 2012 to June 2013


The HSMR reports mortality at Trust level across the NHS in England using standard and transparent methodology.

Aim: Improve HSMR rate. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, patient outcomes & reputation.

The Trust HSMR (source: Dr Foster) for July 2012 to June 2013 was 91.17 – better than expected. The Trust has consistently maintained an overall HSMR within or better than the expected range over the latest available 4 year period.

80

85

90

95

100

105

2009/10 2010/11 2011/12 2012/13 2013/14HS

MR

(1

00

x O

bs

erv

ed

/Ex

pe

cte

d d

ea

ths

)

Financial Year

HSMR Trend

LTHT LTHT (rebased) England England (rebased)

NB. "2013/14" accounts for the YTD period April 2013 to December 2013

Acute Trust HSMRs Apr-13 to Dec-13 (not rebased)

Page 28 of 44

VTE Risk Assessment

CSU Jan-14 YTD






Chapel Allerton 98.1% 97.5%



Head & Neck 98.0% 97.1%



Leeds Dental Institute 100.0% 99.7%



Women's 97.4% 96.1%

Trust 96.1% 95.7%

% VTE Risk Assessment


Aim: Ensure at least 95% of adult inpatients have a VTE risk assessment on admission to hospital. Owner: Chief Medical Officer and CSU Clinical Directors. Consequence of failure: Patient safety, clinical outcomes, CQUIN & financial penalty.


The VTE risk assessment indicator is monitored a month in arrears due to the timing of the national reporting deadline.

Provisional Trust performance for February as at 14th March was 96.02%.

70%

75%

80%

85%

90%

95%

100%

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

% p

atie

nts

me

etin

g ta

rge

t

Venous Thromboembolism (VTE) Risk Assessments

% Patients Risk Assessed for VTE Target

70%

75%

80%

85%

90%

95%

100%

% P

atie

nts

Me

etin

g T

arg

et

Trusts


Source: NHS England

Venous Thromboembolism (VTE) Risk Assessments - April to December 2013

RRK University Hospitals Birmingham NHS Foundation Trust 99.2%

RGT Cambridge University Hospitals NHS Foundation Trust 98.8%

RA7 University Hospitals Bristol NHS Foundation Trust 97.7%

RTD The Newcastle Upon Tyne Hospitals NHS Foundation Trust 96.5%

RM2 University Hospital Of South Manchester NHS Foundation Trust 96.2%

Top 5 Performing Peer Trusts - April to December 2013:

Page 29 of 44

Harm Free Care

87

.8%

90

.1%

90

.8%

92

.9%

93

.2%

92

.8%

92

.5%

92

.3%

93

.2%

93

.8%

93

.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4% o

f P

atie

nts

With

Ha

rm F

ree

Ca

re

% of Patients With Harm Free Care

% of Patients With Harm Free Care Target

Source: Safety Thermometer


CQUIN Indicator

Internal Indicator

Aims:

Ensure at least 92% of patients receive harm free care in relation to pressure ulcers, falls, CUTIs & VTE).

Ensure that for the period October 2013 to March 2014 no more than 6.4% of patients have a pressure ulcer (between April and September 2013 this target stood at 7.2%, but was recently renegotiated with the CCG).

Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient safety, patient experience, clinical outcomes, quality of care, reputation and financial penalty.

Actions:

Harm Free Care performance is to be displayed on every adult inpatient ward.

The multi-disciplinary team assessment booklet for falls is to be approved and rolled out across adult inpatient areas.

0%

1%

2%

3%

4%

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% o

f P

atie

nts

With

Fa

lls R

esu

ltin

g i

n H

arm

% of Patients With Falls Resulting in Harm

% Falls With Harm (LTHT) % Falls With Harm (National Acute Average)


0%

2%

4%

6%

8%

10%

12%

14%

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% o

f P

atie

nts

With

a P

ressu

re U

lce

r (n

ew

an

d

old

)

% of Patients With a Pressure Ulcer (New and Old)

% of Patients With a Pressure Ulcer (new and old) Target


0%

2%

4%

6%

8%

10%

12%

14%

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4% o

f P

atie

nts

With

UIT

s (

Ne

w a

nd

Old

)

% of Patients With UTIs (New and Old)

% With UTIs (LTHT) % With UTIs (National Acute Average)


Page 30 of 44

Pressure Ulcers

CQUIN Indicator

Aims:

Reduce the number of grade III pressure ulcers developed in the Trust to no more than 36 for 2013/14.

Reduce the number of grade IV pressure ulcers developed in the Trust to no more than 2 for 2013/14.

Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, patient safety, clinical outcomes, quality of care, CQUIN & financial penalty.

Actions:

The Trust-wide action plan for pressure ulcers is to be refreshed to take into account the CQUINs agreed for 2014/15.

Nursing teams are to continue to work with high risk or high prevalence areas, with audit findings to be included in CSU plans.

0

1

2

3

4

5

6

7

8

9

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

No

. o

f p

ressu

re u

lce

rs

Number of Grade III Pressure Ulcers

Grade III Target

0

1

2

3

4

5

6

7

8

9

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

No

. o

f p

ressu

re u

lce

rs

Number of Grade IV Pressure Ulcers

No. Grade IV

CSU Feb-14

Acute Medicine 4

Trauma and Related Services 2

Digestive Diseases 1

Institute of Oncology 1

Grade III Trust Total 8

Grade IV Trust Total 0

Pressure Ulcers - Grade III

Pressure Ulcers - Grade IV

Page 31 of 44

Complaints

Complaints by CSU YTD

Women's 100

Centre for Neurosciences 97

Digestive Diseases 95

Trauma & Related Services 83

Acute Medicine 80

Hepatorenal 71

Cardio-Respiratory 64

Urgent Care 59

Children's 56

Leeds Cancer Centre 55

Chapel Allerton Hospital 53

Head & Neck 52

Radiology 16

Adult Theatres & Anaesthesia 15

Leeds Dental Institute 12

Adult Therapies 11

Pathology 10

Adult Critical Care 8

All Other CSUs 39

Trust 976

Top Complaints Subjects YTD

Medical Care 421

Communication 133

Nursing care 98

Waiting Lists 78

Attitude 75

Administration 65

Waiting Times 26

Discharge Planning 13

Policy and Procedural Issues 10

Drug Issues 8

Sub Total 927

Trust 976


Internal Indicator

Aim: Improve patient experience and satisfaction through better understanding of the complaints received. Owner: Chief Nurse, CSU Clinical Directors. Consequence of failure: Patient experience, quality of care & financial penalty.

0

20

40

60

80

100

120

140

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4Nu

mb

er o

f C

om

pla

ints

Re

ce

ive

d

Complaints - Number of Complaints Received

0

5

10

15

20

25

30

Ap

r-12

Ma

y-1

2

Ju

n-1

2

Ju

l-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4Ra

te p

er 1

0,0

00

Occu

pie

d B

ed

D

ays

Complaints - Rate per 10,000 Occupied Bed Days

Page 32 of 44

Patient Satisfaction – Friends & Family

Response

Rate

Net Promoter

Score

Response

Rate

Net Promoter

Score

Acute Medicine 38.4% 46 33.8% 48

Cardio-Respiratory 33.2% 71 32.1% 74

Centre for Neurosciences 41.2% 72 29.7% 72

Chapel Allerton Hospital 55.7% 83 53.4% 85

Children's 0.0% - 12.0% 92

Digestive Diseases 44.4% 68 42.3% 67

Head & Neck 40.1% 75 26.9% 64

Hepatorenal 33.3% 65 36.7% 69

Leeds Cancer Centre 25.3% 78 33.0% 79

Trauma & Related Services 34.6% 69 25.1% 67

Urgent Care 56.0% 63 50.4% 65

Women's 16.1% 43 16.8% 59

Inpatient Total 37.0% 66 35.2% 67

Maternity Total 23.7% 71 27.3% 71

A&E LGI 20.8% 49 8.9% 54

A&E SJUH 18.5% 44 9.8% 56

A&E Total 19.7% 47 9.3% 55

Combined Total 26.5% 59 20.5% 64

NB YTD Response Rate is not RAG rated as there is no YTD threshold.

Feb-14 YTD

CSU


Aims:

Ensure at least 20% of eligible patients respond to the Friends and Family Test (FFT) question.

Improve the number of positive recommendations to friends and family (Net Promoter Score) by people receiving NHS Treatment for the place where they received care.

Owner: Chief Nurse, Director of External Affairs & Communication Consequence of failure: Patient experience, reputation, CQUIN & financial penalty. Appendix 2 lists the peer Trusts included in the benchmarking graph.

The FFT will be extended to all NHS services in England, including Outpatient appointments, by the end of March 2015. Actions:

Work is underway to implement the iWantGreatCare "gold package" in existing areas, which will increase the depth of feedback available – above and beyond the standard FFT requirements.

Planning has commenced for the roll-out of the FFT to Daycases, Children's and Outpatients - ahead of the NHS England April 2015 deadline.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

% R

esp

on

se

Ra

te

Friends and Family Test - % Response Rate

Response Rate (%) Target

0

10

20

30

40

50

60

70

80

Ja

n-1

3

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Ju

n-1

3

Ju

l-1

3

Au

g-1

3

Se

p-1

3

Oct-

13

Nov-1

3

Dec-1

3

Ja

n-1

4

Fe

b-1

4

Ne

t P

rom

ote

r S

co

re

Friends and Family Test - Net Promoter Score

Net Promoter Score (LTHT) Net Promoter Score (National Avg)*

*Excludes Independent Sector providers. Reported a month in arrears.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Re

sp

on

se

Ra

te

Trusts


Source: NHS England

Friends and Family Test Response Rates (A&E and Inpatient)January 2014

Page 33 of 44

Outpatient Measures

Feb-14 YTD Feb-14 YTD

Radiology 374 3,861 12.5% 12.2%

Leeds Cancer Centre 2,259 25,650 16.3% 15.9%

Trauma and Related Services 1,499 18,201 17.5% 18.2%

Womens 1,735 19,431 19.5% 19.0%

Leeds Dental Institute 1,104 14,221 17.6% 20.6%

Adult Theatres & Anaesthesia 35 439 23.2% 22.1%

Head & Neck 3,373 45,404 20.0% 22.3%

Childrens 1,477 17,529 22.8% 22.9%

Chapel Allerton Hospital 2,661 32,639 21.7% 23.3%

Cardio-Respiratory 1,744 20,756 22.7% 23.4%

Hepatorenal 1,743 21,488 21.0% 23.6%

Pathology - 19 - 25.7%

Digestive Diseases 1,330 16,874 24.3% 25.9%

Centre for Neurosciences 1,539 16,440 29.1% 26.6%

Acute Medicine 743 11,076 22.9% 26.6%

Adult Therapies 88 1,364 24.3% 27.8%

Adult Critical Care 4 31 26.7% 28.4%

All other CSUs - 1 - 100.0%

Trust 21,708 265,424 20.3% 21.4%

Total Number of OP Appointment

Cancellations (By Patient and Hospital)

OP Appointment Cancellations (as a %

of Total Bookings)

Outpatients: Total Appointment Cancellations

CSU

Internal Indicator

Aims:

Ensure the Trust’s Did Not Attend (DNA) rate is below the peer average.

Reduce the number of appointments cancelled by hospital within 6 weeks of appointment.

Reduce the number of appointments cancelled by patient within 6 weeks of appointment.

Owner: Director of Informatics and CSU Clinical Directors. Consequence of failure: Patient experience, clinical outcomes & financial penalty.

Actions:

A review of the automated appointment messaging service pilot is to be completed, with an aim to rollout the service to all booked Outpatients appointments in 2014/15.

The weekly Outpatient publication continues to highlight under 6 week hospital cancellations for CSUs to review and action.

Radiology 355 11.9% 3,672 11.6% 19 0.6% 182 0.6%

Leeds Dental Institute 720 11.5% 8,868 12.9% 198 3.2% 2,599 3.8%

Womens 973 10.9% 10,972 10.7% 654 7.3% 6,789 6.6%

Acute Medicine 408 12.6% 5,383 12.9% 195 6.0% 2,772 6.7%

Trauma and Related Services 780 9.1% 8,484 8.5% 524 6.1% 7,121 7.1%

Leeds Cancer Centre 927 6.7% 11,675 7.2% 1,163 8.4% 11,728 7.2%

Adult Critical Care 4 26.7% 22 20.2% 0 0.0% 8 7.3%

Cardio-Respiratory 1,011 13.2% 11,079 12.5% 471 6.1% 6,878 7.7%

Adult Therapies 62 17.1% 905 18.4% 23 6.4% 395 8.0%

Head & Neck 1,702 10.1% 20,629 10.1% 1,131 6.7% 16,928 8.3%

Childrens 672 10.4% 8,007 10.5% 607 9.4% 6,495 8.5%

Adult Theatres & Anaesthesia 15 9.9% 266 13.4% 20 13.2% 173 8.7%

Chapel Allerton Hospital 1,377 11.3% 15,619 11.2% 932 7.6% 12,275 8.8%

Hepatorenal 998 12.0% 11,064 12.2% 650 7.8% 8,166 9.0%

Digestive Diseases 718 13.1% 8,550 13.1% 504 9.2% 6,687 10.3%

Centre for Neurosciences 613 11.6% 7,650 12.4% 687 13.0% 6,356 10.3%

Pathology - - 7 9.5% - - 11 14.9%

All other CSUs - - - - - - - -

Trust 11,335 10.6% 132,852 10.7% 7,778 7.3% 95,563 7.7%

Outpatients: Appointments Cancelled Within 6 Weeks of Appointment

CSU

Cancelled by Patient (Number and as a

% of Total Bookings)

Cancelled by Hospital (Number and as a

% of Total Bookings)

Feb-14 YTD Feb-14 YTD


General Medicine 1.2% 5.8%

Gastroenterology 8.1% 8.0%

Neurosurgery 8.4% 7.5%

Gynaecology 9.1% 6.9%

Cardiology 9.3% 8.7%

Rheumatology 9.6% 9.3%

Elderly Medicine 9.7% 9.4%

Urology 10.1% 8.5%

Ophthalmology 10.3% 9.0%

Respiratory Medicine 10.4% 10.2%

Dermatology 10.7% 8.3%

General Surgery 11.4% 9.8%

Trauma & Orthopaedic Surgery 11.5% 9.3%

Ear Nose & Throat 12.0% 8.7%

Neurology 12.2% 10.8%

Plastic Surgery 12.3% 9.6%

Oral Surgery 15.2% 11.6%

All Specialties 9.5% 8.6%

Outpatient Appointment DNA (%)

Selected Specialties - Jan-13 to Dec-13

0% 5% 10% 15% 20%

General Medicine

Gastroenterology

Neurosurgery

Gynaecology

Cardiology

Rheumatology

Elderly Medicine

Urology

Ophthalmology


Dermatology

General Surgery

Trauma & Orthopaedic…

Ear Nose & Throat

Neurology

Plastic Surgery

Oral Surgery

Ou

tpa

tie

nt A

pp

oin

tme

nt

DN

A (%

)

LTHT Peer Average


Outpatient Appointment DNA (%)Selected Specialties - Jan-13 to Dec-13

Page 34 of 44

Outpatient Measures (Continued)


General Medicine 0.4 0.6

Gastroenterology 0.9 1.6

Gynaecology 1.1 1.0

Ear Nose & Throat 1.1 1.4

Neurosurgery 1.3 1.6

Oral Surgery 1.5 1.1

Cardiology 1.6 1.5

Elderly Medicine 1.6 1.8

Plastic Surgery 1.8 2.6

General Surgery 1.9 1.9

Respiratory Medicine 1.9 2.5

Trauma & Orthopaedic Surgery 1.9 2.0

Dermatology 2.9 2.4

Urology 3.1 2.4

Neurology 3.1 2.3

Ophthalmology 3.4 3.1

Rheumatology 4.1 4.4

All Specialties 2.0 2.3

New to Review Ratio: Selected Specialties

Jan-13 to Dec-13

0

1

2

3

4

5

Genera

l Medic

ine

Gastroente

rolo

gy

Gynaec

olo

gy

Ear

Nose

& T

hro

at

Neuro

surg

ery

Ora

l Surg

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LTHT Peer Average


Outpatient New to Review Ratio: Selected Specialties - Jan-13 to Dec-13

Actions:

At the end of February, there were 4,578 patients waiting more than 3 months over their due date for a review appointment; over half of these were waiting for appointments within the Digestive Diseases CSU. Whilst the number waiting more than 3 months over their due date has reduced from 1,895 at the end of August to 1,514 at the end of February in Colorectal Surgery, the number overdue in Gastroenterology has risen over the same period from 961 to 1,226.

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No of Gastroenterology Patients Waiting >3 Months Achieve Trajectory

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 *

Acute Medicine 201 3 0 0 0 0 1 0 q

Institute of Oncology 12 15 1 1 3 9 1 0 q

Radiology 0 0 1 0 0 0 0 0 u

Women's 4 1 0 2 1 0 23 29 p

Childrens 267 144 100 20 19 71 22 72 q

Cardio-Respiratory 5 2 10 71 248 43 45 84 p

Hepatorenal 668 555 582 620 658 569 439 95 q

Trauma and Related Services 225 173 38 196 409 230 200 102 q

Head & Neck 784 64 1 2 13 64 117 107 q

Leeds Dental Institute 142 164 88 57 147 300 446 350 p

Centre for Neurosciences 235 269 313 225 365 288 311 376 p

Chapel Allerton Hospital 534 262 332 445 1,220 1,116 533 499 q

Digestive Diseases 1,619 1,964 2,462 2,683 2,426 2,970 2,704 2,864 p

Trust 4,696 3,616 3,928 4,322 5,509 5,660 4,842 4,578 q

* As at 28/02/2014

NB. The "Trend" column indicates whether the number of patients waiting has risen, remained the same or fallen since the end of Q1 2012/13.

Trend

Outpatient Follow-Up Waiting List - Patients >3 Months Over their Due Date at Quarter End

CSU2012/13 2013/14

Page 35 of 44

Choose and Book (CAB) – ASIs

Specialty Name ASIs

Surgery - Breast 118

Cardiology 104

Dermatology 100

Children's & Adolescent Services 98

Endocrinology and Metabolic Medicine 90

Neurology 76

Diagnostic Physiological Measurement 74

Ear, Nose & Throat 65

GI and Liver (Medicine and Surgery) 50

Gynaecology 49

2 Week Wait Suspected Cancer 49

Respiratory Medicine 24

Surgery - Plastic 11

Pain Management 11

Orthopaedics 10

Rheumatology 4

Surgery - Not Otherwise Specified 4

Ophthalmology 3

Geriatric Medicine 2

Haematology 1

Urology 1

Surgery - Vascular 1

ASIs - February 2014


Aim: Reduce the number of appointment slot issues (ASIs) to no worse than 2% above the national average. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes & financial penalty.

CAB ASIs is a percentage of ASIs generated from within Choose and Book out of all Directly Bookable Service (DBS) bookings. Actions:

ASIs are reviewed on a daily basis and are escalated to CSU meetings to review and increase capacity in line with demand.

ASIs are also reviewed at weekly access meetings with the Trust's central performance team.

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Choose and Book - Appointment Slot Issues (ASIs)

LTHT National Penalty Threshold

Page 36 of 44

CAB - Utilisation

Internal Indicator

Aim: Improve the percentage of appointments booked via CAB out of all first GP referrals to the target level of 90%. Owner: Director of Informatics, CSU Business Managers, CSU Clinical Directors Consequence of failure: Reputation, timely access to treatment, patient experience, clinical outcomes.

CAB utilisation is a national measure based on bookings made via the CAB system out of the estimated total number of GP referrals to first outpatient appointments.

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Page 37 of 44

Workforce

CSU Feb-14

Adult Therapies 82.5%

Medicines Management and Pharmacy Services 74.0%

Radiology 73.2%

Urgent Care 70.8%

Leeds Dental Institute 70.6%

Adult Theatres & Anaesthesia 65.1%

Children's 62.0%

Acute Medicine 62.0%

Hepatorenal 61.9%

Centre for Neurosciences 60.3%

Women's 57.7%

Cardio-Respiratory 57.4%

Trauma & Related Services 56.0%

Adult Critical Care 54.0%

Chapel Allerton 52.1%

Pathology 48.8%

Digestive Diseases 48.3%

Leeds Cancer Centre 44.1%

Head & Neck 43.0%

Outpatients 41.3%

Trust 57.4%1 Percentage of staff who have an in date appraisal at month end.

Staff Appraised (Ranked by Attainment) 1


Aims:

Reduce sickness absence rates to be in line with the internally agreed trajectory. Current local target is 3.86%.

Meet local target: to ensure 95% of staff have a high quality annual appraisal. Owner: Director of Human Resources and CSU Clinical Directors Consequence of failure:

Sickness absence reduces productivity, places a greater reliance on variable staffing and adversely affects quality.

A failure to appraise staff has a negative impact on staff engagement, productivity and quality.

The Trust-level figures do not include Corporate Services.

CSU Feb-14Mar-13 to Feb-14

(12 Month Rolling Average)

Adult Therapies 3.0% 2.3%

Head & Neck 3.5% 3.1%







Pathology 4.6% 4.2%


Medicines Management and Pharmacy Services 5.6% 4.3%


Radiology 6.4% 4.4%



Women's 3.9% 5.0%




Outpatients 6.2% 5.7%

Trust 4.4% 4.1%

Sickness Absence Rate (Ranked by 12 Month Rolling Average)

CSU Feb-14Mar-13 to Feb-14

(12 Month Rolling Average)



Radiology 0.2% 7.7%




Medicines Management and Pharmacy Services 0.6% 8.4%

Pathology 0.4% 8.6%

Outpatients 1.0% 9.6%


Head & Neck 0.6% 10.1%


Women's 0.1% 11.0%




Adult Therapies 1.2% 14.8%




Trust 0.6% 10.6%2 Excluding Training Grade Doctors

Staff Turnover (Ranked by 12 Month Rolling Average) 2

Page 38 of 44

Finance

AF Finance D ashboard

In-Year Financial Delivery Indicators - February 2014

Category Indicator Plan £'000 Actual £'000 Variance £'000

NHS Financial Performance

Year to Date, Actual compared to Plan 14,908 1,072 (13,836)

Forecast Outturn, Compared to Plan 1,418 609 (809)

Financial Efficiency

Actual Efficiency for Year to Date compared to Plan 35,697 32,840 (2,857)

Recurrent Efficiencies for Year to Date compared to Plan 17,912 14,085 (3,827)

Forecast Outturn Efficiency Compared to Plan 40,242 40,111 (131)

Recurrent Efficiencies for Forecast Outturn compared to Plan 20,448 15,774 (4,674)

Underlying Revenue Position

Forecast Outturn Underlying Revenue Position compared to plan (18,376) (18,272) 104

Cash and Capital

Forecast Year End Charge to Capital Resource Limit 23,192 23,192 0

Temporary PDC for Liquidity Purposes (cumulative sum) 0 0 0

Funding Accessed (cumulative sum) 0 0 0

Progress Towards Foundation Trust Status - February 2014


Progress Towards FT Status

EBITDA Margin Achieved: Year to Date 3 3 (1)

EBITDA Margin Achieved: Forecast Outturn 3 3 0

EBITDA Percentage of Plan: Year to Date 3 4 0

EBITDA Percentage of Plan: Forecast Outturn 3 3 0

Net Return After Financing: Year to Date 4 3 (2)

Net Return After Financing: Forecast Outturn 3 3 0

I&E Surplus Margin net of Dividend: Year to Date 3 2 (1)

I&E Surplus Margin net of Dividend: Forecast Outturn 2 2 0

Liquidity Ratio Days (including NWCF): Year to Date 3 3 0

Liquidity Ratio Days (including NWCF): Forecast Outturn 3 3 0

Combined Financial Risk Rating: Year to Date 3 3 (1)

Combined Financial Risk Rating: Forecast Outturn 3 3 0


Progress Towards FT Status

Liquidity Days 3 1 (2)

Capital Services Capacity 3 3 (1)

Combined Risk Rating 3 2 (1)

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Page 39 of 44

Finance - In-Year Financial Delivery Indicators

Finance - Progress Towards Foundation Trust Status

National Indicator / Quality Requirement National Indicator / Quality Requirement

Income and expenditure is currently showing a significant adverse variance, but this is against the TDA submitted plan which is phased differently to the Board reported plan. The actual Income & Expenditure (I&E) variance reported to the Board currently stands at £7.1 million adverse, and is primarily the result of under-trading against activity plans, and expenditure incurred in the independent sector. The Trust still has a forecast out-turn of £99k surplus as reported to the TDA as part of the 2014/15 annual financial plan submission on 5

th March. The out-turn included in this return is

that reported after technical adjustments relating to income received from the Charitable Trustees. Cost Improvement Programme (CIP) performance is behind plan on a number of specific schemes, but is forecast to almost fully achieve by the year end as a result of non-recurrent income being used to substitute other non-recurrent expenditure schemes that have not delivered. Accountability Framework Summary Performance

The Trust reported a year to date adjusted I&E surplus of £1,072k against a TDA planned adjusted surplus of £14,908k, resulting in an adverse variance of £13,836k.

The I&E variance is forecast to achieve a £99k surplus by the end of the year before technical adjustments, which will result in a £609k deficit after technical adjustments. CIPs are forecast to under achieve by £131k.

Although there is an under-achievement against CIP plans of £2,857k year-to-date, this position is forecast to recover by the end of the financial year as per the comment above.

The Trust is reporting an overall Financial Risk Rating of 3 for the end of February, where it is forecast to remain at the year end with the I&E £99k forecast surplus. The new Continuity of Service ratings are discussed individually below but the overall score is 2. Aspirant foundation trusts should aim for 3.

Indicator Comment

Monitor Combined - Liquidity

Liquidity at the month end was -15.1 days, which equates to a rating of 1. Liquidity has deteriorated marginally from -15.2 days at the end of January but is forecast to remain at 1 at the year end.

Total Capital servicing capacity was 1.77 at the end of February: an improvement on the previous month. This equates to a score of 3, but it is forecast to reduce to 2 at the year end.

Page 40 of 44

Internal Indicators Dashboard

Indicator Dec-13 Jan-14 Feb-14 YTD

RTT clearance time: total (weeks) < 8 10.2 8.6 9.7 n/app

RTT clearance time: over 18 weeks (weeks) < 0.5 1.0 0.7 0.7 n/app

RTT: Patients Waiting Over 18 Weeks at Month-End (Incomplete) - Admitted 912 754 678 n/app

Cancelled Operations: Last Minute Cancellations for Non-Clinical Reasons

A&E: Time from arrival to initial full assessment (mins) - 95th percentile < 15 16 14 16 15

A&E: Time from arrival to treatment (mins) - median < 60 78 73 84 78

A&E: % Unplanned follow-up re-attendances within 7 days < 5% 8.2% 8.1% 8.0% 7.9%

A&E: % Patients leaving A&E unseen < 5% 3.0% 2.6% 3.6% 3.3%

A&E: Number of trolley waits greater than 12 hours 0 0 0 0

Patient handovers taking longer than 15 minutes between ambulance and A&E 780 816 732 7582



Cancer 62 days: referrals following consultant upgrade > 85% 61.5% 66.7%Reported a month

in arrears80.6%

Stroke patients spending at least 90% of their time in hospital on a stroke unit > 80% 72.0% 67.0%Reported a month

in arrears79.7%

Proportion of high-risk TIA patients investigated and treated within 24 hours of first contact with a health professional 71.1% 77.6%Reported a month

in arrears75.9%

MRSA Screening > 95% 96.5% 96.5% 96.1% 95.7%

CDI cases: Rate per 100,000 Occupied Bed Days 25.3 21.8 18.3 23.8

Harm Free Care: % of Patients With Falls Resulting in Harm (Snapshot) 0.5% 0.7% 0.4% n/app

Harm Free Care: % of Patients With UTIs (new and old) (Snapshot) 4.1% 4.0% 3.4% n/app

Number of complaints 62 81 92 976

OP Measure: DNA rate Peer ave: 8.6%

8,103 12,495 11,335 132,852

9.0% 10.1% 10.6% 10.7%

7,016 9,083 7,778 95,563

7.8% 7.3% 7.3% 7.7%

OP Measure: New to Review ratio Peer ave: 2.3 2.0

Jan-13 to Dec-13

Jan-13 to Dec-13

0

OP Measure: Number of OP Appointment Cancellations By Patient Within 6 Weeks of Appointment (and as % of Total

Bookings)

OP Measure: Number of OP Appointment Cancellations By Hospital Within 6 Weeks of Appointment (and as % of Total

Bookings)

Thresholds

As per NHS Standard

Contract

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9.5%

Key Indicators (not in other dashboards)

Page 41 of 44

Indicator Dec-13 Jan-14 Feb-14 YTD

OP Activity: New (Attendances) 18,111 24,745 21,548 244,331

OP Activity: Review (Attendances) 43,037 63,650 55,638 639,540

IP Activity: Elective (Spells) 7,093 10,723 9,802 117,166

IP Activity: Non-elective (Spells) 5,768 6,393 5,678 67,461

Length of Stay Peer ave: 4.8

Choose and Book: Appointment Slot Issues 10.8% 6.7% 15.2% 10.9%

Choose & Book utilisation > 90% 55.8% 64.6% 63.1% 60.2%

Research & Innovation (R&I): Activity - Research studies in NIHR portfolio (number) Q3: 411 (2nd) n/app

R&I: Participation - Participants recruited to NIHR Portfolio Studies (number) Q3: 8374 (8th) n/app

R&I: Initiation – all clinical trials should take 70 Days or less from receipt of a valid research application to 1st patient visit

(median) < 70 Q3: 82 days n/app

R&I: Delivery – all commercial clinical trials should recruit the agreed target number of patients within the agreed recruitment

period (%)> 80% Q3: 60% n/app

Dementia Stage 1: Find - % of all patients aged 75 and above admitted as emergency inpatients who are asked the

dementia case finding question within 72 hours of admission or who have a clinical diagnosis of delirium on initial

assessment or known diagnosis of dementia.

95.3% 96.2% 94.1%

Dementia Stage 2: Assess - % of all patients aged 75 and above admitted as emergency inpatients who have scored

positively on the case finding question, or who have a clinical diagnosis of delirium and who do not fall into the exemption

categories reported as having had a dementia diagnostic assessment including investigations.

96.9% 94.9% 94.7%

Dementia Stage 3: Refer - % of all patients aged 75 and above, admitted as an emergency inpatient who have had a

diagnostic assessment (in whom the outcome is either “positive” or “inconclusive”) who are referred for further diagnostic

advice/follow up.

98.0% 94.4% 96.2%

Reported a month

in arrears

Within top 5 Trusts in

England

> 90%

Within top 5 Trusts in

England

Reported quarterly

No worse than 2%

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average

Thresholds

Jan-13 to Dec-13 : 5.1

Key Indicators (not in other dashboards) (continued)

Page 42 of 44

Appendix 1 - Updates

Updates from Regulators

CQC publishes findings from first wave of pilot inspections 1

The CQC has published its findings from the 18 pilot hospital inspections undertaken in 2013. Although the report concludes that compassionate care is alive and well, as well as a strong commitment to the NHS, inspectors found significant variations in quality between trusts and even between services within trusts. It also found that apart from critical care and maternity, most services cannot demonstrate whether they are delivering effective care or not. As a result of lessons learnt, the CQC has made a number of changes to its inspection methodology, including:

o Collection of more information, especially from national clinical audits, to enhance its assessments of effectiveness.

o Routinely asking for more specific information from trusts in advance of the site visits, so that it can incorporate this into the key lines of enquiry.

o A reduction in the number of information requests made to trusts during the site visit.

o An in depth, pilot assessment of complaints during the pre-inspection phase.

o Case tracking of a sample of recent patients with comorbidities or complex needs, a review of a sample of safety incidents, and a review of board minutes.

CQC publishes updates to Intelligent Monitoring reports 2

The CQC has published an updated set of Intelligent Monitoring reports, which include refreshed data and changes to the indicators used. The reports monitor a range of information, including patient experience, staff experience and performance, to cover the CQC’s five key domains: safe, effective, caring, responsive, and well-led.

2013 National Inpatient Survey Results published

3

The results of the National Inpatient Survey 2013, which are based on a sample of consecutively discharged inpatients who attended the Trust between June and August 2013, have been published. A total of 1,700 patients were sent the questionnaire, of which 715 were returned complete – giving a response rate of 43%. Although the results show improvement in some areas, performance has remained the same overall. The results are currently being analysed in full detail in order to identify priority areas for future development.

NHS England publishes reports into Leeds Children’s Heart Surgery Unit 4

NHS England has published two reports into the children’s heart services provided at the Trust, which were commissioned following the temporary suspension of services in 2013. They include a Mortality Case Review, which looks at 35 deaths identified by the National Institute for Cardiovascular Outcomes Research for the years 2009-2013, and a Family Experience Report, which tells the stories of 16 families' experience at the unit during the same time period. The Mortality Case Review concludes that on current evidence, services at Leeds are safe and running well; however, the Family Experience Report highlights issues with care and compassion. The Trust has stated that it will continue its commitment to improvement and learning by receiving the recommendations outlined in the Family Experience Report and developing and delivering tangible actions that will improve the service further.

1 The CQC’s new approach to inspecting NHS acute hospitals: Initial findings

2 Hospital intelligent monitoring: Summary of indicator changes

3 2013 National Inpatient Survey Results

4 Leeds children’s heart surgery services review

http://www.cqc.org.uk/sites/default/files/media/documents/20140305_acute_wave_1_report_-_final_for_publishing_2_formatted.pdf

http://www.cqc.org.uk/sites/default/files/media/documents/20140213_summary_of_indicator_changes_for_ceo_letter_17feb14.pdf

http://intouch.leedsth.nhs.uk/uploads/1394710892_in-patient%202013%20full_2.pdf

http://www.england.nhs.uk/ourwork/patientsafety/leeds-chil-hr/

Page 43 of 44

Appendix 2 - Peer Groups

Peer Groups FFT, Complaints, Never Events, OP DNA, OP New to Review, LoS and VTE: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool and Broadgreen University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospital Southampton NHS Foundation Trust - University Hospitals Birmingham NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals Of Leicester NHS Trust RTT: As above, plus the following providers: - Guy’s and St Thomas’ NHS Foundation Trust - Imperial College Healthcare NHS Trust - King’s College Hospital NHS Foundation Trust - University College London Hospitals NHS Foundation Trust A&E: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Oxford University Hospitals NHS Trust - Royal Liverpool And Broadgreen University Hospitals NHS Trust - Sandwell And West Birmingham Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - University Hospital Of South Manchester NHS Foundation Trust - University Hospitals Of Leicester NHS Trust

Listed below are the Trusts used to benchmark performance. HCAI: - Brighton & Sussex University Hospitals - Cambridge University Hospitals - Central Manchester University Hospitals - Chelsea & Westminster Hospital - Guy's & St. Thomas' - Imperial College Healthcare - King's College Hospital - Nottingham University Hospitals - Oxford University Hospitals - Plymouth Hospitals - Royal Free Hampstead - Royal Liverpool & Broadgreen University Hospitals - Salford Royal - Sheffield Teaching Hospitals - South Tees Hospitals - St. George's Healthcare - The Newcastle upon Tyne Hospitals - University College London Hospitals - University Hospital Birmingham - University Hospital of South Manchester - University Hospital Southampton - University Hospitals Bristol - University Hospitals Coventry & Warwickshire - University Hospitals of Leicester Cancer: - Cambridge University Hospitals NHS Foundation Trust - Central Manchester University Hospitals NHS Foundation Trust - Nottingham University Hospitals NHS Trust - Sheffield Teaching Hospitals NHS Foundation Trust - The Christie NHS Foundation Trust - The Newcastle Upon Tyne Hospitals NHS Foundation Trust - The Royal Marsden NHS Foundation Trust - University Hospitals Bristol NHS Foundation Trust - University Hospitals of Leicester NHS Trust

Page 44 of 44

Appendix 3 - Glossary

Glossary SJUH - St James's University Hospital TBC - To Be Confirmed TDA - Trust Development Authority VTE - Venous Thromboembolism WHO - World Health Organisation YAS - Yorkshire Ambulance Service YTD - Year to Date

AF - Accountability Framework ASI - Appointment Slot Issue CAB - Choose and Book CAS - Central Alerting System CCG - Clinical Commissioning Group CDI - Clostridium Difficile Infections CIP - Cost Improvement Programme CQC - Care Quality Commission CQUIN - Commissioning for Quality & Innovation CSU - Clinical Service Unit CUTI - Catheter-associated Urinary Tract Infection DBS - Directly Bookable Services DH - Department of Health DNA - Did Not Attend EBITDA - Earnings Before Interest, Tax, Depreciation and Amortisation ED - Emergency Department FFT - Friends and Family Test FT - Foundation Trust GDP - General Dental Practitioners GMP - General Medical Practitioners HCAI - Healthcare Associated Infection HSMR - Hospital Standardised Mortality Ratio I&E - Income & Expenditure IQPR - Integrated Quality & Performance Report KPI - Key Performance Indicator LGI - Leeds General Infirmary LoS - Length of Stay MRSA - Meticillin Resistant Staphylococcus Aureus MSSA - Meticillin Sensitive Staphylococcus Aureus NIHR - National Institute for Health Research R&I - Research & Innovation RAF - Risk Assessment Framework RAG - Red Amber Green RTT - Referral to Treatment SHMI - Summary Hospital-level Mortality Indicator

Documents

Integrated Quality & Performance Report Public Board€¦ · Integrated Quality & Performance Report Public Board 27th March 2014 Presented for: Information Presented by: Dr Mark